In the US, there is an enormous gap between the need for physicians with specialist palliative medicine skills and the supply. Traditional fellowship programs will not be able to supply the number of physicians needed in the next 10-20 years. Innovative approaches to bringing mid-career physicians up to specialist levels are needed to help meet this gap. An effective curriculum for mid-career physicians who wish to develop subspecialist level skills in palliative medicine without participating in an ACGME-accredited fellowship program will help fill this gap. This project takes an innovative approach to training and curriculum development that involves: 1. careful selection of candidates, 2. institutional support, 3. a structured period of both didactic and mentored bedside teaching in the home institution and, 4. short mini-residencies of 4-6 weeks in duration that results in physicians with subspecialist skills. Most evaluation schemes of educational interventions measure attitudes and knowledge. Recent innovations have permitted us to measure some skills. Routine behavioral practice and aggregate patient outcomes have been much more difficult to measure. To provide an independent measure of physician training in hospice and end-of-life care, the designed curriculum will be tested with physician populations and healthcare systems where there are few confounding variables - by training mid-career physicians from developing countries and then bringing the proven curriculum to physicians in the US. By utilizing this trainee population, the curriculum can be tested in an environment with no competing educational interventions and no preexisting indications for/or usage of morphine, and there is the potential to see much greater change than in the usual educational intervention in the United States (US). This application tests the hypothesis that a curriculum in palliative care for mid-career physicians that combines didactic information with bedside mentoring while the physician is building a palliative care program improves patient-care outcomes. The primary endpoint will be an increase in morphine and morphine-equivalent opioid consumption in each country where the intervention is targeted as measured and reported by the International Narcotics Control Board (INCB). Five secondary endpoints will provide data from structured and objective evaluation of skill, attitudes, knowledge, and competence, track number and types of patients seen by the mid-career physicians receiving palliative medicine training, and through changes in the situation in each involved country over time. In this application, we specifically aim to: 1. develop a curriculum for mid-career physicians who wish to acquire subspecialty skills in hospice and palliative medicine and 2. evaluate the outcomes of the curriculum with special emphasis on measures of patient and societal outcomes. PUBLIC HEALTH RELEVANCE: The US must develop medical professionals in palliative care, to relieve suffering and improve the quality of life for those with advanced cancer. There are more than 2.4 million new diagnoses of cancer each year; if the 1 million diagnoses of skin and in situ cancers are excluded, that leaves 1.4 million people with 'serious' cancer, and this number is expected to grow significantly over the next few decades with the aging of the US population. Many of these people will experience significant physical and/or psychological distress as their cancers advance. A proven training program for mid-career physicians will respond to the current shortage of physicians capable of providing adequate palliative care for these patients.